DOCTORING OLD AGE A SOCIAL HISTORY OF GERIATRIC MEDICINE IN VICTORIA Cecily Elizabeth Hunter Submitted in total fulfilment of the requirements of the degree of Doctor of Philosophy February 2003 Department of History and Philosophy of Science University of Melbourne ABSTRACT The pattern of medical practice that emerged in Victoria, following the introduction of a national system of publicly subsidised voluntary hospital and medical insurance by the Liberal-Country Party Coalition government in the early 1950s, was dominated by the provision of individualised, curative medical services based upon a reductionist model of disease. Older adults, classified officially as ‘aged’ according to age of eligibility for the Age Pension introduced in 1909 by the Commonwealth government, were prominent in this pattern of practice. The number of adults over the age of sixty-five increased over the early decades of the twentieth century, and the technical advances made in postwar medicine led to a growing clinical engagement with the degenerative diseases associated with old age. The growing medical involvement with ‘old age’, the basis of the specialist fields of medical practice that proliferated throughout the 1960s, was recognised as such only in relation to the work of general practitioners. Specialist practitioners defined their clinical engagement with old age in terms of pathologies of bodily organs or systems. In contrast, the special role of the GP in relation to elderly patients was defined in terms of that practitioner’s personal knowledge of patients as individuals. Formal designation of the general practitioner as specialist in caring for the sick aged was confined to the Pensioner Medical Service, a component of the national system of remuneration for medical services. Within this pattern of medical practice infirm old people, whose afflictions could not be readily resolved by curative medical services, occupied a residual category outside the field of active medical practice. When poverty compounded the difficulties experienced by these infirm old people they were categorised as a ‘social’ problem to which the appropriate response was the provision of adequate infirmary beds through the charitable efforts of local communities. This pattern of practice emerged out of decades of internal professional debates, and intermittent negotiations with successive federal governments. Social medicine, particularly as it developed in Britain, was 2 a source of ideas for some participants. However, overall, the emphasis upon fee-for-service reflected a widely held view amongst doctors, of the medical practitioner as an apolitical expert in identifying and treating specific disturbances in individual bodies. In Victoria this view was associated with a long-standing tradition whereby individual doctors, local communities and the colonial/state government cooperated to develop acute hospital services. It was as a background to these developments that the benevolent homes in Victoria, funded largely by the state government and managed by voluntary committees, assumed the role of chronic hospitals. They were repositories for patients unwanted in the general hospitals but without anywhere else to go, and infirm old people, - that residual category, ‘the aged’ – were prominent amongst them. The demarcation in Victorian medical practice, between ‘medical’ and ‘social’ problems ensured this change took place without any alteration in the palliative work of the doctors employed there. In the professional environment of Victorian medicine, the introduction of a medical role in the management of infirm old people arose out of a policy decision on the part of the Minister for Health, to manage a growing demand for hospitals and increasing public expenditure. John Lindell, appointed first medical chairman of the Hospitals and Charities Commission in the early 1950s, introduced the role of ‘geriatrician’ into the benevolent home environment, as part of a broader process aimed at organising a fragmented array of local hospitals into a state-wide system serving regional populations. Medical services provided by a general practitioner ‘geriatrician’ outside the acute hospitals would enable the ready discharge of infirm old people, following treatment during acute episodes of illness. At the same time these services were aimed to minimise the need for long-term accommodation (another growing area of state government expenditure). It was, however, events at the national level that influenced the integration of this socio-medical role into the broader profession although under conditions that reinforced the objectives of the Hospitals and Charities Commission. The reform-minded Whitlam Labor government (1972- 1975) funded the development of the socio-medical services promoted by a segment of the medical profession, together with an appropriate 3 knowledge base. This revival of ‘social medicine’ opened up the possibility of integrating the role of ‘geriatrician’ into mainstream medical practice. It did so however, under conditions that meant that geriatric medicine was situated within the broader field of medical rehabilitation on one hand, and on the other hand, the term ‘geriatric service’ referred not so much to the setting for a specialist medical role as to a range of community-based welfare services. The physician geriatrician in Victoria emerged not in response to the specific health problems of elderly people, but as a means of managing increasingly expensive publicly funded hospital services, a response shaped by the organisation of the Australian medical profession. This is to certify that this thesis comprises only my original work towards the PhD, that due acknowledgment has been made in the text to all other material used and that the thesis is less than 100,000 words exclusive of the bibliography and appendices. 4 ACKNOWLEDGEMENTS I am very grateful for the consistent encouragement and perceptive guidance of my supervisors, Associate Professor Warwick Anderson, Dr Anna Howe and Associate Professor Janet McCalman. I thank Dr Helen Verran for her encouragement to take up this challenge and Professor Rod Home and Dr Marilys Guillemin for their kind assistance. Many of the individuals involved in the events described in this thesis have generously given their time to speak to me about their work. These informal conversations were very helpful in enlarging my understanding of the context in which a specialist medical role in treating the infirm aged developed. I would like to thank: Drs D.H. Blake, Herbert Bower, John Hurley, Boyne Russell, Malcolm Scott, and John Shepherd and the late Drs Bruce Ford and Sidney Sax; Professors R.B. Lefroy, Derek Prinsley, and Len Gray and Assoc Prof. Edward Chiu. Dr Shepherd also allowed me the use of his private papers. Mrs Marion Shaw, formerly Executive Officer, Geriatrics Division, Hospitals and Charities Commission, was very helpful in giving me some insight into the work of the Division and, in addition, providing access to the archives of the Australian Association of Gerontology. Miss Shirley Ramsay, one of the first social workers appointed to a position specifically responsible for elderly people, was also generous with her time. I must also acknowledge my family - Alix, Ben, Faith, John, Justin, Rex – each one has, in his or her own particular fashion, helped me in this endeavour. 5 TABLE OF CONTENTS ABSTRACT 2 ACKNOWLEDGEMENTS 5 INTRODUCTION 7 CHAPTER 1 30 OLD AGE IN THE PATTERN OF MEDICAL WORK IN VICTORIA CHAPTER 2 68 THE UNKEMPT GARDEN OF CHRONIC SICKNESS AND INFIRMITY CHAPTER 3 116 BUREAUCRACY, PHILANTHROPY AND MEDICAL INNOVATION CHAPTER 4 157 PSYCHIATRY AND OLD AGE CHAPTER 5 198 GERIATRICS AS MEDICAL WORK CHAPTER 6 238 PERCEIVING THE ‘SICK MAN’ IN THE OLD PERSON IN TROUBLE CHAPTER 7 289 MEDICINE OF SENESCENCE OR MANAGING THE SYSTEM? BIBLIOGRAPHY 316 APPENDICES 348 6 INTRODUCTION This thesis addresses the question of how it has been possible for health and illness in old age in Victoria to emerge as the focus of a specialist field of medical practice. Superficially, the answer is quite clear: the first attempts to develop a special medical role in the provision of services for the elderly in the late 1950s coincided with the appearance of increasing numbers of elderly individuals in the Victorian population, although proportionately they remained a small group because of the high birthrate and level of immigration. In the period since the early 1970s, when the Australian Geriatrics Society was formed with the aim of promoting geriatric medicine, the proportion of the population classified as ‘aged’ has grown, making the association between the development of geriatric medicine and the shift towards an older population quite explicit.1 It appears only ‘natural’ in these circumstances, that there should develop a geriatric medicine defined as, ‘that branch of general medicine concerned with the clinical, preventive, remedial and social aspects of illness in the elderly’, and that the Society should nominate as its first aim, the promotion of the highest standards of medical care for the aged.2 However, this change in the constitution of the population has meant that, overall, medical practitioners in all fields are concerned with health and illness in old age. The elderly, classified as such on the basis of age of eligibility for the Age Pension, since the 1940s at least have made up a significant proportion of patients in both hospital and community. Since the 1960s, doctors working in specialist areas of practice such as medicine 1 Between 1954 and 1976, the period covered in this thesis, the percentage of the Victorian population aged 65 years and over, changed little, from 8.6 per cent to 8.9 per cent. In absolute numbers the change was more noticeable; 210,000 in 1954 to almost 334,000 in 1976. A high birth rate and sustained immigration accounted for stability in the proportion of the population in this age group, A. Howe, ‘Report of a Survey of Nursing Homes in Melbourne’, Working Paper no 10, October, 1980, p.18. In 1981 the percentage of the Victorian population over the age of 65 was 9.8; in 1991, 11.1; in 1994, 12.1, A.